Deliver comprehensive primary care and continuous healthcare services to PACE participants through assessments and individualized care plans. Collaborate with an interdisciplinary team to manage specialist referrals, medications, and safe transitions of care.
Requirements summary
Requires a valid license as an MD, DO, APRN, NP, or PA with DEA registration and BLS certification. Preference is given to candidates with board certification in Geriatrics and at least two years of direct patient care experience.
professional certificatepostgraduate degreeCare PlanningPatient AssessmentPatient EducationGeriatric CareInterdisciplinary Team CollaborationClinical DocumentationDischarge PlanningRisk Adjustment CodingPrimary CarePhysical ExaminationMedication ReconciliationChronic Disease Management
Job description
Join BoldAge PACE and Make a Difference!
Why work with us? • A People First Environment
We make what is important to those we serve important to us.
Make an
Impact: Enhance the quality of life for seniors.
Professional
Growth: Access to training and career development.
Competitive Compensation
Medical/Dental
Flex Time Off
401K with Match
Life Insurance
Tuition Reimbursement
Flexible Spending Account
Employee Assistance Program
Be part of our mission!
Are you passionate about helping older adults live meaningful, independent lives at home with grace and dignity? BoldAge PACE is an all-inclusive program of care, personalized to meet the individual health and well-being needs of our participants. Our approach is simple: We listen to our participants and their caregivers to truly understand their needs and desires.
PCP Nurse Practitioner
Job summary
Delivering primary care and continuous healthcare services to PACE participants, utilizing the knowledge and skills required to assess, plan, and provide care in alignment with PACE Program standards. Works closely with the clinical care team to conduct assessments, reassessments, develop care plans, and deliver comprehensive primary care.
Essential duties and responsibilities
Provide high-quality primary care with a strong focus on individualized evaluation, starting with a comprehensive history and physical exam, rather than defaulting to broad diagnostic testing panels.
Collaborate closely with the IDT before referring participants to specialists, ensuring referrals are necessary and that continuity of care is maintained.
Collaborate with the Medical Director to manage specialist referrals, initiate appropriate treatment prior to referral when indicated, review specialist notes promptly, and develop and communicate participant care plans that incorporate clinical judgment and consult findings to ensure comprehensive care.
Manage and monitor all of your participants' medications, aiming to exceed expectations in medication reconciliation, and medication interactions. This can be done in conjunction with the Medical Director and our collaborating Pharmacist vendor.
Benefits
Dental Insurance
Employee Assistance Program
Life Insurance
Medical Insurance
Flexible Spending Account
Tuition Reimbursement
Flex Time Off
401K With Match
Stay actively informed of participant status during hospitalizations and facility stays, providing appropriate guidance to ensure safe transitions and care continuity.
Assume shared responsibility for all participants in the center, regardless of individual assignment, supporting the IDT model of team-based care.
Participate in and contribute to daily IDT meetings, offering clinical insights and collaborating on participant-centered care plans.
Ensure accurate, timely completion of all participant assessments and documentation in compliance with policy, regulatory, and quality standards.
Review and respond to labs, imaging, and consults in a timely manner, incorporating findings into ongoing care plans and communicating changes with the IDT.
Educate participants and caregivers on self-care strategies, medication use, and wellness practices, empowering them to participate in their own care.
Use the Emergency Department judiciously, prioritizing PACE resources unless symptoms are potentially life-threatening.
Accurately document diagnoses with attention to proper coding practices, supporting risk adjustment and quality reporting metrics.
Provide coverage for the 24/7 on-call rotation, addressing participant needs promptly and ensuring proper hand-offs and communication.
Contribute to discharge planning, supporting smooth transitions across care settings.
Assist with staff training and mentoring, contributing to clinical policy development and best practice implementation.
Participate in ongoing performance and quality improvement initiatives.
Demonstrate flexibility by stepping into other roles, as allowed by licensure and experience, when needed to support the team.
Maintain and report clinical resource needs to the Medical Director, supporting effective operations.
Consistently uphold all safety, privacy, and compliance standards.
Experience and education
Md, do, aprn, np, or pa
Current State license
State CDS Certification and DEA Registration
Board Certified in Geriatrics preferred
BLS required (must have within 90 days of employment)
2 years experience providing direct patient care (preferred)
1 year of experience working with a frail or elderly population preferred. If this is not present, training will be provided upon hiring (If applicable for the role).
Pre-Employment requirements
Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
Pass a comprehensive criminal background check that may include, but is not limited to, federal and state Medicare/Medicaid exclusion lists, criminal history, education verification, license verification, reference check, and drug screen.
BoldAge PACE provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
